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Mpk"K-1U114 1V111 M4; f"1VVVo41,:U 9911t;11 JUU11 iiu1 V 1 —F-1) 11 1111 •rY11"' " . <br /> APPLICATION <br /> 111,11i9 Non-Transferable, Revocable, and Suspendabl-4 <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Ap.plicatiorVs h re y m e� on sine i e jurisdictional area of the Joaqui cal Healt Dist <br /> W Business DBA) Address J <br /> ? Owner ! Uzi Address 0'. <br /> J Firm Partners, Addresses a elephone Numbers <br /> 0. Business Telephone Emergency Telephone No. <br /> � Contractor Licence N <br /> a Applicants Name (Pr <br /> in <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites . <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. _CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address -- <br /> 2. ❑ PUMPER YARD 6-41 <br /> For July 1, _ June 30, 19 <br /> O <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stored -- <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ___. R.S. or R.C.E. No. <br /> Test Location —_.. Test Date/Time – -- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 11-10 <br /> �?er ESSPOOL Address ��d�F <br /> �TANK�O SEPTICCLEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> EV'PERMANENT ❑ TEMPORARY ❑ NEW VkHEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name __ ___ Where Certified <br /> Plant Location -- -- <br /> Plant Capacity __ - - -- No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre red this applic nand at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es nd r gulation of S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 6 Received By July 3 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � \ <br /> LESS — <br /> PRORATION j� ,l/0 <br /> � <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ley 10 <br /> Received by Date Receipt No. Perm�o. Iss a e Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.e.go 2009 STOCKTON,CA 95201 <br />